Use of Medical Care: How People in Informal Employment Rate Access to Health Services Figure 2.4 Use of medical care, by income 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% regular use low use regular use low use regular use low use regular use low use regular use low use regular use low use Senegal Zambia Kenya Benin Côte d'Ivoire Ethiopia less 0.5 MW 0.5 MW-1 MW>1 MW-2 MW>2 MW Note: Households included only if they reported cases of sickness during the past 12 months. As Ethiopia has no statutory minimum wage, we use 1,500 Birr/month as substitute for the minimum wage. those we call here the extreme poor – hardly use medical treatment(Benin 42.9 per cent; Senegal 39.5 per cent). For Côte d’Ivoire and Ethiopia, the situation is only slightly better. A quarter report that they have not used health care services. In Kenya and Zambia, this share is considerably less, at 13.7 per cent and 13 per cent, respectively. Higher income in itself is not a sufficient condition for se­curing medical care. Even in Kenya, only 90.5 per cent of the highest income segment report good use of medical treatment at all times. In Benin and Senegal, less than half of the»well-off« gave a positive response. The»well-off« in Côte d’Ivoire, Zambia and Ethiopia fare little better. Income clearly facilitates the use of medical care. But it does not do so for all, and a significant number of fairly well-off people are still left without medical care. We can therefore assume that supply shortages play a role here as well. 8 2.2.5 Discussion 9 All the surveyed countries still have large numbers of citizens for whom the use of health care can only be called precar­ious. While even the»best performers« among our survey group are far away from providing care for all, there are huge differences between the countries, which merits a com­8 We have to emphasize again that the evaluation measures the use of medical care and not the quality of medical treatment or satisfaction with the medical care received. It may well be that the quality of med­ical treatment equally depends on income and people’s capacity to pay for lower or higher standards of treatment. If so, inequality arising from income differentials could be even higher. ment. Even though this is not the place to compare in detail respondents’ perceptions of health service availability, a sim­ple look at WHO statistics immediately points to enormous national differences that mirror respondents’ perceptions. Kenya and Zambia fare better than Benin and Senegal on all indicators listed in Table 2.1, while Ethiopia and Côte d’Ivoire are positioned in the middle. Kenya and Zambia spend more of their GDP on health, which also translates into higher per capita expenditures. Importantly, the share of expenditure invested in primary health care is substantially larger, which increases the provision of health care for the poor. They em­ploy more medical doctors and nurses to care for patients. Out-of-pocket payments(OOP), which measure the share of direct payment for health-care goods and services from personal sources, serve as an indicator of the burden health costs impose on a household. Here again, Kenya and Zam­bia fare much better than the other four countries. Clearly, Zambia 10 and Kenya provide significantly more funding for primary health care and appear to provide easier access to medical care with fewer social funding barriers than Benin and Senegal. Côte d’Ivoire and Ethiopia take a middle posi­9 This chapter does not include an analysis of the use of medical care by age and education. The age of the household head is statisti­cally not correlated with the use of medical care(see Appendix Table 2.A3) while the household head’s level of education is(see Appendix Table 2.A4). Education is closely linked to income, however, and pro­vides the same insight into social disparities as what we get from in­come. 10 Zambia under the National Health Care Package(NHCP) offers basic health-care packages at the primary(district) level free of charge. Ca­pacity constraints and funding shortages do not always allow unlim­ited access to medical care under the NHCP. For details, see: WHO (2017). 11